The mission of Prognosis is to explore the nexus at which healthcare policy meets healthcare practice and how one affects the other. This blog makes readers more aware of the innovations taking place in healthcare delivery, financing and technology and the types of public policies that will encourage further progress.

Healthcare In Focus is a public education initiative of the HLC, created to promote a constructive dialogue about the state and future of American healthcare.

The open enrollment season for the federal health insurance exchange begins tomorrow, November 1, and runs through December 15 for coverage that will become effective at the start of 2019. Consumers will notice some significant improvements this year when they begin the process of selecting a health plan.

The most important of these is price. Average premiums, as measured by the second-lowest-cost silver plans, will drop for the first time since the exchanges began in 2014. The average 1.5 percent price reduction is a striking change from the average double-digit increases that have been seen in recent years and tells us that steps taken to stabilize the marketplace have had a positive effect.

I want to also credit Seema Verma and her team at the Centers for Medicare and Medicaid Services (CMS) for some important changes that have been made on the healthcare.gov website to assist consumers in finding the right health plan to fit their needs.

Among those changes are an improved interface (based on consumer input), an enhanced tool to help users search for local agents and brokers who can assist them in selecting and enrolling in a plan, and a “window shopping” function that allowed consumers to browse plans and prices even before open season began and without having to fill out an application.

Improvements like these are making the health insurance exchanges more of a consumer-focused system and the reduction in average premium prices is welcome news indeed for those of us who want to see the competitive marketplace succeed

It’s campaign season, so that means we’re seeing an escalation in the number of politicians who insist that the federal government must involve itself in “negotiating” prices for the Medicare Part D prescription drug program. (I put negotiating in quotations because it’s a misnomer to suggest that government negotiates in the understood sense of the world. It is closer to reality to say that the feds set prices.)

The problem with this assertion regarding Medicare Part D is that the facts keep getting in the way.

Last week, the Centers for Medicare and Medicaid Services announced that average monthly premiums for Part D plans are expected to drop from $33.59 in 2018 to $32.50 in 2019. This is the second consecutive year in which average premiums will have declined and follows several previous years in which premium levels remained relatively flat. In other words, the inference that urgent action is needed to fundamentally change the Medicare Part D structure isn’t supported by any evidence that consumers are being harmed by the status quo.

In fact, the approach employed when Congress created the Medicare prescription drug program just over a decade ago remains just as viable today. The best way to maintain affordability is to empower consumers to select from several competing drug plans on the basis of value. Part D enrollees will naturally gravitate to the plans that cover the drugs their physicians prescribe and do so at affordable cost.

That’s not to say there aren’t actions that need to be taken regarding Part D. For example, Congress needs to act expeditiously to address the “out of pocket cliff,” the forthcoming change in the out-of-pocket spending threshold that must be met in order to qualify for catastrophic coverage. If not address, this “cliff” will cost beneficiaries several hundred dollars that many can’t afford.

On the whole, though, when politicians tell you this political season that we need a heavier government hand in Medicare Part D pricing, please be aware that the numbers don’t back up that claim.

There is legislation – the Pandemic and All-Hazards Preparedness Reauthorization Act – moving through the U.S. Senate right now that is essential in reauthorizing critical programs improving our public health infrastructure and response capabilities whenever an emergency occurs, last year’s hurricanes in Puerto Rico and the Gulf Coast still being all too fresh in our memories. There is a provision in this measure that deserves highlighting.

The House of Representatives Energy and Commerce Committee included language from the Good Samaritan Health Professionals Act. The Good Samaritan legislation essentially protects medical volunteers who offer their services during a large-scale disaster from lawsuits. When a tornado, hurricane, or even a major pandemic strikes, we want physicians, nurses and other medical professionals to rush to the scene and provide their healing expertise to victims. Due to inconsistencies in federal and state medical liability laws, though, these volunteers risk being turned away or having their assistance limited because of lawsuit concerns.

This legislation ensures that our priorities are in the right place – making sure that people in urgent circumstances receive the help they desperately need. This legislation had bipartisan support in the House and we look forward to it receiving the same level of backing in the U.S. Senate. The legislation must pass both houses before September 30.

In the 15 years since its inception, the increase in popularity of Medicare Advantage (MA) – health coverage provided by private plans in contrast to traditional fee-for-service (FFS) Medicare – has been undeniable. Roughly half of all Medicare-eligible seniors are enrolled in Medicare Advantage plan and that proportion keeps rising.

Now there is a new addition to the growing body of evidence that MA plans are not only serving their enrollees well, but is bringing greater overall value to the Medicare program than that generated by the FFS approach.

Overall, the Avalere study found that MA beneficiaries had 23 percent fewer emergency stays and 33 percent fewer emergency room visits than their peers in FFS coverage. This wasn’t the result of MA plans enrolling healthier individuals at the outset. Rather, the study found that a greater percentage of MA beneficiaries were in clinical and social risk categories that traditionally drive up costs in FFS Medicare.

Avalere found that MA outperformed FFS on a range of cost, utilization, and outcome metrics in caring for individuals with one or more chronic health conditions. Among patients with diabetes, for example, those enrolled in MA experienced 73 percent fewer serious clinical complications than FFS beneficiaries. And patients dually eligible for Medicare and Medicaid – who generally have more complicated and serious health conditions – had 49 percent fewer hospital visits and a 17 percent lower average-cost-per-beneficiary in MA plans.

Former Congresswoman Allyson Schwartz, president and CEO of the Better Medicare Alliance (of which the Healthcare Leadership Council is a member) said “this study adds to the growing body of evidence showing the ability of Medicare Advantage to align incentives to better manage the care for a high-need population with multiple chronic conditions.” These patients, of course, account for the most significant portion of our country’s healthcare spending.

This study adds fuel to the argument that we can enhance healthcare quality and better contain spending through improved patient health when healthcare entities compete on the basis of value.

It’s indisputable that the opioid addiction crisis with which America is currently grappling is one of historic magnitude. We’re losing more than 115 people per day from opioid overdoses. Families and communities are being devastated and public resources – healthcare, social services, law enforcement – are being stretched thin.

This is a serious problem, but it is not an insolvable one. Recently, the Healthcare Leadership Council, working with over 70 organizations from the healthcare, employer, patient advocacy, and addiction treatment sectors, released a “Roadmap for Action” consisting of over 30 achievable, high-impact solutions to address opioid misuse and addiction. The Roadmap is the product of several weeks of deliberations, idea sharing and consensus building and represents a collaboration of unprecedented breadth to address a national public health crisis.

This package of solution addresses both regulatory and legislative priorities but, just as importantly, it includes actions that healthcare leaders should take. Winning this battle will require a public-private effort. And the recommendations we’re offering, some of which are detailed in the following paragraphs, reflect this broad-based strategy.

Health sector leaders have a responsibility to improve access to evidence-based, non-opioid and non-pharmacological pain management therapies. (It’s vital to recognize that, in taking on the opioid crisis, we cannot place obstacles between millions of Americans suffering from chronic and acute pain and the treatments they need.) Developing and evaluating these treatments will require long-term evidence generation and data collection, but their proliferation will cut costs and improve outcomes for patients in the long run.

We must also focus on improving data-driven coordinated care, and in order to do this we must create access to real-time prescribing data within the clinician workflow. Improving critical data access must also include legislative action to change a law known as 42 CFR Part 2 to allow confidential information sharing on SUD diagnosis history while still adhering to the Health Insurance Portability and Accountability Act (HIPAA). It is important that patients’ privacy be protected, but it is also vital that care providers understand their patients’ substance abuse histories if they are to provide them with the well-informed care that they need.

And we must develop sustainable payment frameworks that prioritize quality, coordinated, value-based care connecting patients with the medical resources they need, whether that be a pharmacist, primary care provider, nurse practitioner, licensed addiction treatment professional, or certified peer recovery specialist. In fact, we must engage the full community of medical professionals in coordinated care to treat patients struggling with substance use disorder.

This is just a sample of the comprehensive, multi-faceted plan we’re going to be advancing. No single organization, regulatory agency or legislative body can solve this crisis by themselves. Working together, though, we have the ability to save lives and prevent tragedies. The time for bold and decisive action is now.